How To Fix Denial Code 66 | Common Reasons, Next Steps & How To Avoid It

Denial Code 66 (CARC) means that a claim has been denied because the service billed is applied towards the patient’s blood deductible. Below you can find the description, common reasons for denial code 66, next steps, how to avoid it, and examples.

2. Description

Denial Code 66 is a Claim Adjustment Reason Code (CARC) and is described as ‘Blood Deductible’. This indicates that the insurance company will not make the payment for the billed service because the cost is being allocated towards meeting the patient’s blood deductible. In simpler terms, the claim is not payable until the patient’s blood deductible is fully satisfied.

2. Common Reasons

The most common reasons for denial code 66 are:

1. Unmet Blood Deductibles: Patients often face Denial Code 66 when their blood deductible has not yet been fully paid. Insurance plans typically require the deductible to be met before covering the costs of blood-related services, leading to denials if claims are submitted for reimbursement before this threshold is reached.
2. Misunderstood Deductible Accumulations: Confusion about how much of the blood deductible has already been paid can lead to premature claim submissions. Providers may not have updated or accurate information about a patient’s blood deductible status, including misunderstandings regarding which blood-related services have contributed towards the deductible and the total amount accumulated to date.
3. Incorrect Application of Deductible Credits: Blood-related services that should be applied towards the deductible might be incorrectly processed, either due to billing errors or misinterpretation of insurance policy terms. This can result in services not being recognized as contributing to the blood deductible, leading to unexpected denials.
4. Inaccurate Coding and Billing Information: Claims may be denied under Code 66 due to inaccuracies in the submitted information, such as incorrect patient identifiers, service codes for blood-related services, or date of service. These errors can mistakenly signal to the insurer that the blood deductible has not been met, even if it has, or vice versa.
5. Lack of Coordination of Benefits: In scenarios where patients have multiple insurance policies, a lack of coordination can lead to Denial Code 66. This occurs when there is confusion over which policy’s blood deductible applies and how much has been satisfied across policies, resulting in denials due to unmet blood deductible requirements.

3. Next Steps

You can fix denial code 66 as follows:

1. Confirm Blood Deductible Status: First, verify the patient’s current blood deductible status with the insurance company. Determine if the services billed were indeed applied towards the blood deductible and if the patient’s blood deductible has not been fully met for the policy period.
2. Accuracy Check on Claim: Review the claim for accuracy in patient information, service codes for blood-related services, and dates of service. Errors in these areas can mistakenly trigger Denial Code 66 even if the blood deductible situation is correctly applied.
3. Patient Communication: Engage with the patient to discuss their blood deductible obligations. Clarify that the services billed were applied towards their blood deductible and inform them of any remaining blood deductible amount. This step ensures transparency and can help manage patient expectations regarding out-of-pocket costs.
4. Documentation and Resubmission: If after verifying the blood deductible status and ensuring claim accuracy you find that the denial was in error, prepare documentation supporting the claim’s validity. This may include records showing prior blood deductible payments or proof of insurance policy details that might have been overlooked. Then, resubmit the claim with this additional documentation to challenge the denial.
5. Liaise with Insurance: If there’s confusion or disagreement about the blood deductible application, directly contact the insurance company’s provider support. Discuss the specifics of the claim and the rationale behind its denial. This can lead to a resolution or clarification on how to properly apply charges towards the blood deductible.
6. Adjust Billing Practices: Based on the outcome, it may be necessary to adjust billing practices for future claims. This could involve more detailed pre-verification of patient insurance benefits, including blood deductible status, before blood-related services are rendered.

4. How To Avoid It

You can prevent denial 66 in the future as follows:

1. Determine Blood Deductible Status: Before blood-related services are rendered, verify each patient’s insurance coverage, focusing on the blood deductible. Confirm how much of the blood deductible has already been met and the amount remaining.
2. Detail Verification: When preparing claims for blood-related services, meticulously verify that all patient information, service codes, and billing details are accurate. Special attention should be given to the blood deductible status to ensure that claims are appropriately filed. Accurate billing can prevent denials resulting from discrepancies that could mistakenly indicate a blood deductible has not been met.
3. Clarify Insurance Coverage: Educate patients about their insurance benefits, with a particular focus on how blood deductibles work and their role in the billing process for blood-related services. Clear communication can help set expectations regarding out-of-pocket expenses and reduce confusion or dissatisfaction stemming from blood deductible-related denials.
4. Focus on Blood Deductibles: Regularly train your billing and administrative staff on the latest insurance policies and billing procedures, with a special emphasis on understanding and handling blood deductibles. Equip your team with the knowledge to identify blood-related services that may be affected by the blood deductible and how to address Denial Code 66 effectively.

5. Example Cases

Below are two examples of denial code 66:

• Example 1: In a typical scenario, a healthcare provider might submit a claim for a blood transfusion costing $2,000. If the patient’s blood deductible is $5,000 and they haven’t incurred any blood-related costs for the year, the claim would be denied under Code 66, indicating the $2,000 will go towards the blood deductible.
• Example 2: Another example involves a situation where a provider mistakenly submits a claim for a blood test under a patient’s old insurance plan, leading to a denial since the blood deductible specifics do not match the current policy.

Source: Claim Adjustment Reason Codes